Rheumatology is a specialty focused on complexity. Doctors work in a world of systemic autoimmune conditions where treatment courses are extended, multi-territorial, and may include some of the most sophisticated and costly medications available.
This medical complexity generates a corresponding complexity in the revenue cycle of the practice. For rheumatology clinics, good medical billing is an integral part of care for the patient. It ensures the patient access to life-altering therapies while keeping the clinic afloat financially.
But the road to proper reimbursement is fraught with special challenges. From dealing with costly biologics to explaining long-term treatment, rheumatology practices encounter a special set of medical billing challenges. The following are seven of the biggest hurdles and real-world approaches to overcome them.
1. The High-Stakes World of “Buy and Bill” Biologics
The Challenge: Most biologic infusions utilized to treat diseases such as rheumatoid arthritis or psoriatic arthritis are obtained under the “buy and bill” model. The practice buys these extremely costly drugs upfront and then bills the insurance company for both the drug itself and its administration. This model places rheumatology practices at great financial risk. One denied claim can cost a practice thousands of dollars.
The Solution: Install a secure inventory and verification system. Prior to purchasing a biologic, a specific staff member must conduct a thorough, real-time insurance verification to ensure the patient’s individual coverage for the particular drug. Get prior authorization before the drug is even ordered. In addition, utilize a strong inventory management system to track each vial from purchase through administration, so that there is accurate medical coding and billing and avoidable errors do not result in unnecessary expense.
2. The Crushing Burden of Prior Authorizations
The Challenge: Prior authorizations are one of the greatest headaches in all of medicine, but they are especially severe in rheumatology because so many of the drugs are very expensive. Insurers put strict conditions on these medications, requiring extensive documentation to demonstrate medical necessity, which imposes a tremendous administrative burden of over 12 hours a week, and can hold up necessary care for patients with pain.
The Solution: Design a standardized, proactive prior authorization process. Establish checklists for major payers and medications that specify the required clinical information. Assign a “prior authorization guy” or a medical billing PA team to handle submissions and follow-ups. Use specialized software that automates parts of the process and monitors submission status to significantly lower administrative workload and reduce delays as well.
3. Coding for Overlapping and Complex Diagnoses
The Challenge: Rheumatology patients infrequently come with a lone, uncomplicated problem. Precisely portraying this complexity using ICD-10 codes is essential to validating the extent of care provided. Coding with a single, non-specific code can result in down-coding and reduced reimbursement.
The Solution: Accentuate provider education for coding specificity. Clinicians must be taught to note down all the coexisting conditions and associate each with the respective treatment or evaluation. Your medical billing staff should be skillful at sequencing codes appropriately, listing the primary reason for the visit first and then all pertinent chronic conditions. This portrays the entire picture of the patient’s health status to the payer.
4. Justifying Medical Necessity for Long-Term Care
The Challenge: Chronic rheumatological diseases need to be managed over the course of many years. Payers might doubt long-term treatment strategies and deny claims for follow-up visits or ongoing therapy if they don’t perceive obvious evidence of medical necessity.
The Solution: Document, document, document. For each follow-up appointment, the provider’s note should say more than that the condition is “stable.” It should address the effectiveness of the treatment, an analysis of side effects, and a clear plan for future management. Based on objective measures, there is tangible data that explains to the payer why continued management is medically necessary.
5. Dealing with Payer-Specific Policies
The Challenge: Little standardization exists between insurance payers. Each has its own individual policies as to which drugs are in its formulary, what clinical criteria must be satisfied for approval, and what documentation is needed. Monitoring these constantly changing rules for multiple payers is a monumental task for any practice.
The Solution: Establish a “payer policy library.” As you receive an update to a policy from an insurer, store it in an accessible, centralized spot. When submitting a claim for an expensive service, rapidly scan that particular payer’s rules. Building close relationships with provider representatives of your significant payers can also be a good source for both resolving disputes and explaining rules.
6. Handling Denials and Underpayments
The Challenge: With all that complexity, some denials are unavoidable. However, many rheumatology practices don’t have a formal process for dealing with them. Denied claims become a low priority, or underpayments are routinely taken without complaint, resulting in substantial revenue leakage over the long run.
The Solution: Put in place a data-driven denial management program. Follow up on every single denial and group it according to reason. Review this data on a monthly basis to detect patterns. If you notice a sudden increase in denials for a particular procedure from one payer, you can determine the underlying cause and put in place a corrective action plan. A bold, coordinated appeals process is vital to optimizing the revenue for your practice.
7. Inefficient Financial Communication to Patients & Collection
The Challenge: Many rheumatology clinics often struggle to communicate financial responsibilities to the patient parties clearly; this leads to delayed or, sometimes even, missed payments. Patients get confused by complex bills or are unaware of their co-pays and deductibles upfront.
The Solution: Hire a revenue cycle management company that can implement patient-friendly medical billing systems while also offering multiple payment options and setting up automated reminders. They also help clinics estimate costs in advance and collect pre-authorizations. As a result, cash flow improves significantly and bad debt gets reduced — all while ensuring patient satisfaction.
By going after these medical billing and coding challenges aggressively with specialty processes and by subcontracting to specialist staff, rheumatology clinics are able to establish a robust revenue cycle so that they can continue to deliver exceptional care to their patient base.
